Medicare Blue Choice Value Plus (HMO)(H3351-013)

by Excellus Health Plan Inc - Wayne County, NY

The plan offers national in-network prescription coverage. This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

$3 400 out-of-pocket limit. All plan services included.

Doctor and Hospital Choice

You must go to network doctors specialists and hospitals.

Referral required for network specialists (for certain benefits).

Inpatient Hospital Care

No limit to the number of days covered by the plan each hospital stay.

$375 copay for each Medicare-covered hospital stay

$0 copay for additional hospital days

$1 125 out-of-pocket limit every year.

Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

Inpatient Mental Health Care

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

$375 copay for each Medicare-covered hospital stay.

"The maximum out-of-pocket limit is covered under ""Inpatient Hospital Care""."

Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

Skilled Nursing Facility (SNF)

Authorization rules may apply.

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For Medicare-covered SNF stays:

Days 1 - 100: $50 copay per day

Home Health Care

Authorization rules may apply.

$0 copay for Medicare-covered home health visits

Hospice

You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

$0 copay for all preventive services covered under Original Medicare at zero cost sharing:

Abdominal Aortic Aneurysm screening

Bone Mass Measurement

Cardiovascular Screening

Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)

Colorectal Cancer Screening

Diabetes Screening

Influenza Vaccine

Hepatitis B Vaccine

HIV Screening

Breast Cancer Screening (Mammogram)

Medical Nutrition Therapy Services

Personalized Prevention Plan Services (Annual Wellness Visits)

Pneumococcal Vaccine

Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only)

Smoking Cessation (Counseling to stop smoking)

Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)

HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details.

The plan covers the following supplemental education/wellness programs:

Written health education materials including Newsletters

Nutritional benefit

Health Club Membership/Fitness Classes

Nursing Hotline

Copays may apply for these benefits.

Kidney Disease and Conditions

$0 copay for renal dialysis

$0 copay for kidney disease education services

Outpatient Prescription Drugs

20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.excellusbcbs.com and www.univerahealthcare.com on the web.

Different out-of-pocket costs may apply for people who

have limited incomes

live in long term care facilities or

have access to Indian/Tribal/Urban (Indian Health Service) providers.

The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by both you and a Part D plan.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.

"You pay $0 the first time you fill a prescription for certain drugs. These drugs will be listed as ""free first fill"" on the plan+s website formulary printed materials and on the Medicare Prescription Drug Plan Finder on Medicare.gov."

If you request a formulary exception for a drug and Medicare Blue Choice Value Plus (HMO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug.

$0 deductible.

Supplemental drugs don't count toward your out-of-pocket drug costs.

You pay the following until total yearly drug costs reach $2 930:

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$6 copay for a one-month (30-day) supply of drugs in this tier

$40 copay for a one-month (30-day) supply of drugs in this tier

$90 copay for a one-month (30-day) supply of drugs in this tier

33% coinsurance for a one-month (30-day) supply of drugs in this tier

$15 copay for a three-month (90-day) supply of drugs in this tier

$100 copay for a three-month (90-day) supply of drugs in this tier

$225 copay for a three-month (90-day) supply of drugs in this tier

33% coinsurance for a three-month (90-day) supply of drugs in this tier

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$6 copay for a one-month (31-day) supply of drugs in this tier

$40 copay for a one-month (31-day) supply of drugs in this tier

$90 copay for a one-month (31-day) supply of drugs in this tier

33% coinsurance for a one-month (31-day) supply of drugs in this tier

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$15 copay for a three-month (90-day) supply of drugs in this tier

$100 copay for a three-month (90-day) supply of drugs in this tier

$225 copay for a three-month (90-day) supply of drugs in this tier

33% coinsurance for a three-month (90-day) supply of drugs in this tier

After your total yearly drug costs reach $2 930 you receive a discount on brand name drugs and pay 86% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 700.

$2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.

Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Medicare Blue Choice Value Plus (HMO).

You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 930:

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$6 copay for a one-month (30-day) supply of drugs in this tier

$40 copay for a one-month (30-day) supply of drugs in this tier

$90 copay for a one-month (30-day) supply of drugs in this tier

33% coinsurance for a one-month (30-day) supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 700.

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of:

5% coinsurance or

$2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

Dental Services

$0 copay for the following preventive dental benefits:

up to 2 oral exam(s) every year

up to 2 cleaning(s) every year

up to 2 dental x-ray(s) every year

$40 copay for Medicare-covered dental benefits

Hearing Services

Hearing aids not covered.

$40 copay for Medicare-covered diagnostic hearing exams

$40 copay for up to 1 supplemental routine hearing exam(s) every year

Vision Services

$40 copay for one pair of eyeglasses or contact lenses after cataract surgery.

$0 to $40 copay for exams to diagnose and treat diseases and conditions of the eye.

$0 to $40 copay for up to 1 supplemental routine eye exam(s) every year

$0 copay for glasses

$0 copay for contacts

$75 plan coverage limit for eye wear every year.

Over-the-Counter Items

The plan does not cover Over-the-Counter items.

Transportation

This plan does not cover supplemental routine transportation.

Acupuncture

This plan does not cover Acupuncture.

Premium and Other Important Information

In 2012 the monthly Part B Standard Premium is $99.90 and the annual Part B deductible amount is $140.

If a doctor or supplier does not accept assignment their costs are often higher which means you pay more.

Most people will pay the standard monthly Part B premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Doctor and Hospital Choice

You may go to any doctor specialist or hospital that accepts Medicare.

Inpatient Hospital Care

In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day

"A ""benefit period"" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

Inpatient Mental Health Care

In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

Skilled Nursing Facility (SNF)

In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay are: Days 1 - 20: $0 per day Days 21 - 100: $144.50 per day

100 days for each benefit period.

"A ""benefit period"" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

Home Health Care

$0 copay.

Hospice

You pay part of the cost for outpatient drugs and inpatient respite care.

You must get care from a Medicare-certified hospice.

Doctor Office Visits

20% coinsurance

Chiropractic Services

Supplemental routine care not covered

20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible.

"""Partial hospitalization program"" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization."

Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital.

You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit.

Not covered outside the U.S. except under limited circumstances.

Urgently Needed Care

20% coinsurance or a set copay

NOT covered outside the U.S. except under limited circumstances.

Outpatient Rehabilitation Services

20% coinsurance

Durable Medical Equipment

20% coinsurance

Prosthetic Devices

20% coinsurance

Diabetes Programs and Supplies

20% coinsurance for diabetes self-management training

20% coinsurance for diabetes supplies

20% coinsurance for diabetic therapeutic shoes or inserts

Diagnostic Tests X-Rays Lab Services and Radiology Services

20% coinsurance for diagnostic tests and x-rays

$0 copay for Medicare-covered lab services

Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests like checking your cholesterol.

This applies to program services provided in a doctor+s office. Specified cost sharing for program services provided by hospital outpatient departments.

Preventive Services and Wellness/Education Programs

No coinsurance copayment or deductible for the following:

Abdominal Aortic Aneurysm Screening

Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions.

Cardiovascular Screening

Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk.

Colorectal Cancer Screening

Diabetes Screening

Influenza Vaccine

Hepatitis B Vaccine for people with Medicare who are at risk

HIV Screening. $0 copay for the HIV screening but you generally pay 20% of the Medicare-approved amount for the doctor+s visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.

Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35-39.

Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but aren+t on dialysis or haven+t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease

Personalized Prevention Plan Services (Annual Wellness Visits)

Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information.

Prostate Cancer Screening + Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50.

Smoking Cessation (counseling to stop smoking). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits.

Welcome to Medicare Physical Exam (initial preventive physical exam) When you join Medicare Part B then you are eligible as follows. During the first 12 months of your new Part B coverage you can get either a Welcome to Medicare Physical Exam or an Annual Wellness Visit. After your first 12 months you can get one Annual Wellness Visit every 12 months.

Kidney Disease and Conditions

20% coinsurance for renal dialysis

20% coinsurance for kidney disease education services

Outpatient Prescription Drugs

Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan or you can get all your Medicare coverage including prescription drug coverage by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.

Dental Services

Preventive dental services (such as cleaning) not covered.

Hearing Services

Supplemental routine hearing exams and hearing aids not covered.

20% coinsurance for diagnostic hearing exams.

Vision Services

20% coinsurance for diagnosis and treatment of diseases and conditions of the eye.

Supplemental routine eye exams and glasses not covered.

Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.

Annual glaucoma screenings covered for people at risk.

Over-the-Counter Items

Not covered.

Transportation

Not covered.

Acupuncture

Not covered.

Point of Service

You may go to any doctor specialist or hospital that accepts Medicare.

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or a prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription.

• Cost Plans

A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan's network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services, or urgently needed services).

• Deductible

The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.

• HMO - Health Maintenance Organization

Local HMOs are plans with defined networks of providers, which beneficiaries must use in order to receive coverage, serving specific geographic areas consisting of aggregations of counties.

• HMO SNP - Special Needs Plan

Medicare Special Needs Plans are a type of Medicare Advantage Plan (Part C) for people with certain chronic diseases and conditions or who have specialized needs (such as people who have both Medicare and Medicaid or people who live in certain institutions). Medicare SNPs provide their members with all Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance) services, and Medicare prescription drug coverage (Part D). Medicare SNPs were created to give certain groups of people better access to Medicare with plans designed to meet their unique needs.

• HMO with POS Option

An HMO POS is a Medicare Advantage Plan that is a Health Maintenance Organization with a more flexible network allowing Plan Members to seek care outside of the traditional HMO network under certain situations or for certain treatment.

• LPPO - Local Preferred Provider Organization

Local PPOs are network based plans that serve specific geographic areas consisting of aggregations of counties, like HMOs, but with more flexibility in provider choice within the network. Beneficiaries may use providers outside the network but will pay more out of pocket cost.

Help is available. If you have limited income and resources, you may qualify for help paying your Medicare health care and/or
prescription drug coverage costs. For more information, visit socialsecurity.gov, call Social Security at 1-800-772-1213, or apply for help at your State Medical Assistance (Medicaid) office.

If you have questions about Medicare, visit medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.